Observations
Based on a review of client records, the facility failed to obtain a written informed and voluntary consent from the client for the disclosure of information contained in the client record in one of two client records reviewed.
Client #1 was admitted on May 27, 2026 and was discharged on June 23, 2026. The release of information form to the funding source was signed by the client on June 23, 2026; however, there was evidence of disclosures to the funding source prior to the client signing the consent to release information form.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The patient signed the consent late and has since been discharged. If the patient returns for treatment, a new consent will be obtained during the initial visit.
An electronic dashboard has been implemented to monitor the consent signature compliance. The dashboard will be monitored weekly to ensure all consents are signed at the time of admission by the Program Manager. A weekly compliance report is generated and distributed to program leadership. If non-compliance is identified a call will be made to the patient to request that they sign the appropriate documents. Any patient information requested by external stakeholders will not be sent until the patient signs the appropriate forms.
Process Changes to Prevent Recurrence:
1. A hard stop has been added to the Electronic Medical Record (EMR) that prevents clinicians from proceeding with a patient visit until the required consent is signed. Effective as of 6/30/26.
2. A reminder text has been embedded in the New Patient Template. Effective as of 5/29/26.
3. A column was added in all provider schedules in our EMR that indicates to the provider when the consent needs to be collected. Effective as of 5/29/26.
4. A weekly data report of all patients seen in A-START was developed with columns indicating whether the consent forms were appropriately completed.
5. A virtual check-in process for patients seen via telehealth has been implemented and all patients will be required to complete the consent forms prior to joining the visit. Effective as of 5/12/26.
6. Staff received training on the importance of timely consent completion and on all of the above tools to ensure compliance. Education was completed on June 15, 2026.
Monitoring and Sustainability:
Program leadership will actively monitor ongoing compliance with consent requirements and provide additional staff education and reinforcement as needed based on monitoring results.
Compliance of completion of required consents is monitored through weekly electronic audits beginning on 5/1/26. Reports are generated every Monday, reviewed by the Program Manager, and shared with program leadership to identify trends, address deficiencies, and ensure sustained compliance through ongoing quality assurance and performance improvement (QA/PI) activities.
The audit monitoring will continue for the next 3 months ensuring 100% compliance is achieved. The dashboard will continue to monitor compliance, and the weekly reports will continue to be sent to the program leadership. This will be a continuous process.
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